Connecting Care for Patients: Interdisciplinary Care Transitions and Collaboration addresses practical strategies for creating connected, seamless, and transparent health care for patients in settings outside of the hospital. It presents antidotes to healthcare fragmentation caused by inefficient care, patient safety problems, patient dissatisfaction, and higher costs. The text focuses on clinical case management, interdisciplinary referrals and conferencing, cross-functional team meetings, tracking patients in value-based purchasing programs, inpatient liaison visits, structured collaboration with physician groups, and referral sources, and the development of clinical community networking groups. Further, it explores tools for patient self-management support, effective integration of technology, family caregiver engagement, and techniques for addressing health disparities and other high-risk care gaps.
A unique resource, this text blends conceptual information with practical tools and strategies for connecting care for patients by describing research and evidence-based techniques while translating them into actionable tools. Also included are chapter objectives, review questions, explanations of key terms, case studies, self-assessments, scripts, trigger questions, and detailed descriptions of each tool and technique.
"This book refers to multiple patient safety, quality, and regulatory tables, figures, and resources and is well organized (see Contents, Preface, Reviewers, Chapters, Epilogue, and Index). My favorite figure was in Chapter 10: High-Risk Gaps and Cracks I: Social Determinants of Health, Health Disparities, and Mental Health: Figure 10-1, High-Risk Gaps and Cracks in Care."
-- Debra DellaRatta, MSN, CPHQ (James A. Haley Veterans' Hospital) Doody's Review
In the preface, the author describes the book as a culmination of her own experiences as a nurse, manager, patient, healthcare consultant, mother, caregiver for elderly parents, and advocate within a family caregiver support network. The book is geared toward nursing and other allied health professionals including information technology specialists, performance improvement/Lean Six Sigma professionals, data analysts, and patients.